Late Stenting After Heart Attack Fails To Help

In two randomized trials reported today at the American Heart Association Scientific Sessions in Chicago, angioplasty and stenting procedures performed from 3 to 28 days after the onset of a heart attack failed to improve patients' outcomes.

When cardiologists open totally blocked coronary arteries within the first few hours of the onset of a heart attack, patients' outcomes are significantly improved. Unfortunately, more than 1/3 of patients having a heart attack don't show up within the critical 12-hour window of opportunity. Still, most cardiologists have assumed that opening the blocked arteries even beyond that 12-hour window would be useful, because an open artery seems intrisically better than a closed one.

Both the Total Occlusion Study of Canada (TOSCA-2) and the Occluded Artery Trial (OAT) enrolled heart attack patients (more than 2000 patients in OAT) who missed that critical 12-hour time window. Patients were randomized to standard medical therapy vs. standard medical therapy plus "late" stenting to open the occluded artery.

Neither study showed any long-term benefit from these late stenting procedures. Indeed, in OAT, there was a surprising trend toward more heart attacks later on in patients randomized to the late stent group.

In recent years, many cardiologists have been routinely performing these late stenting procedures in heart attack patients who, for one reason or another, were unable to have stenting procedures performed acutely. (This routine practice actually made it somewhat difficult to find cardiologists willing to enroll patients in these trials.) Cardiologists being a logical, dispassionate, non-avaricious, science-minded and data-driven group of physicians, the results of these two randomized trials ought to curtail much if not most of this activity.